phil health

PhilHealthPhilHealthPresented by:Presented by:

Flolet C. AguirreFlolet C. AguirreLeana M. DizonLeana M. Dizon

Jeadverl F. GuintoJeadverl F. GuintoMaria Louise M. MunarMaria Louise M. Munar

Rochelle Ann S. PanganRochelle Ann S. PanganDominick D. CanlasDominick D. Canlas

Rashid Paul P. GeronaRashid Paul P. GeronaKevin Ashley L. YapKevin Ashley L. Yap

MARIA Project

August 4, 1969

PMCC

House Bill 14225 and Senate Bill 01738

Philippine Health Insurance Corporation (PhilHealth)

HistoryHistory

Vision

Mission

Core Values

People and PartnershipHarmonyInnovationLeadershipHonor, Accountability and TransparencyExcellence and Lifetime LearningHealth for All

Vision, Mission and Core Values

Vision, Mission and Core Values

Know the Rules!Know the Rules!• PhilHealth does not pay for all your

health care costs.

• PhilHealth pays only for covered items and services when its rules are met.

• Members usually give a co-payment for the portion of the actual cost that is not covered by PhilHealth

• PhilHealth does not pay for all your health care costs.

• PhilHealth pays only for covered items and services when its rules are met.

• Members usually give a co-payment for the portion of the actual cost that is not covered by PhilHealth

PhilHealthPhilHealth• Govt owned and controlled corporation

• Created by Republic Act 7875

• National Health Insurance Program (NHIP)

• Amended by Republic Act 9241

• Access to health care is a basic right of citizens – “Universal coverage”

• Govt owned and controlled corporation

• Created by Republic Act 7875

• National Health Insurance Program (NHIP)

• Amended by Republic Act 9241

• Access to health care is a basic right of citizens – “Universal coverage”

Members andDependents

Members andDependents

Our MembersOur Members

1. Employees (govt and private)

– monthly payment (3% salary)

2. Individually Paying Program (voluntary)

- quarterly payment (1,200/year)

3. Overseas Workers Program

- Annual payment (900/year)

1. Employees (govt and private)

– monthly payment (3% salary)

2. Individually Paying Program (voluntary)

- quarterly payment (1,200/year)

3. Overseas Workers Program

- Annual payment (900/year)

Our MembersOur Members4. Non-paying (pensioner)

- no payment for life

• 60 years old

• With total 120 monthly contributions

5. Sponsored (thru partnership with LGUs)

- annual payment, eligibility for 1 year

4. Non-paying (pensioner)

- no payment for life

• 60 years old

• With total 120 monthly contributions

5. Sponsored (thru partnership with LGUs)

- annual payment, eligibility for 1 year

Your DependentsYour Dependents

• Spouse

• Children < 21 years old

• Parents > 60 years old

• Spouse

• Children < 21 years old

• Parents > 60 years old

BenefitsBenefits

45 Days Annual Allowance45 Days Annual Allowance

• 45 days allowance per year for the principal (member)

• Another 45 days shared among dependents

• 45 days allowance per year for the principal (member)

• Another 45 days shared among dependents

Your benefitsYour benefits• Illness requiring hospitalisation

• Outpatient:– Surgical procedures

• Cataract surgery• BTL• Vasectomy• Endoscopy• Excision• Suturing

• Illness requiring hospitalisation

• Outpatient:– Surgical procedures

• Cataract surgery• BTL• Vasectomy• Endoscopy• Excision• Suturing

Drugs and MedicinesDrugs and Medicines

• Only drugs used during confinement will be paid

• Drugs must be written in generic name

• Closed formulary – only drugs listed in the preferred list* will be covered by PhilHealth

*6th edition of the Philippine National Drug Formulary (PNDF)

• Only drugs used during confinement will be paid

• Drugs must be written in generic name

• Closed formulary – only drugs listed in the preferred list* will be covered by PhilHealth

*6th edition of the Philippine National Drug Formulary (PNDF)

Drugs and MedicinesDrugs and Medicines

• Only drugs, supplies, and lab

used on confinement shall be

paid

– Must be supported by official

receipts

• Only drugs, supplies, and lab

used on confinement shall be

paid

– Must be supported by official

receipts

• physician charges separately for each patient encounter or service rendered

• expenditures increase if more services are provided or a more expensive service is substituted for a less expensive one

• Needs itemization

• physician charges separately for each patient encounter or service rendered

• expenditures increase if more services are provided or a more expensive service is substituted for a less expensive one

• Needs itemization

Fee for Service Scheme:Fee for Service Scheme:

Benefit Periods

• PhilHealth benefits are divided into benefit

periods

• A benefit period is essentially a single

hospital stay, including re-hospitalisation of

up to 90 days

• In each benefit period, PhilHealth will only

pay 1 benefit

• PhilHealth benefits are divided into benefit

periods

• A benefit period is essentially a single

hospital stay, including re-hospitalisation of

up to 90 days

• In each benefit period, PhilHealth will only

pay 1 benefit

ProfessionalFeeProfessionalFee

PAY TO DOCTOR

Private Patient, Government Hospital

NO Stamp: PF is made to the Chief

PAY TO CHIEF

Service Patient, Pay Hospital

Name of Surgeon

NO Stamp: PF is made to the MD who signed Form 2

Eligibility RulesEligibility Rules

• For employed, at least 3 monthly contributions within the immediate 6 months prior to admission

• the 45-days allowance for room and board has not been consumed yet

• confinement in an accredited hospital of not less than 24 hours

• For employed, at least 3 monthly contributions within the immediate 6 months prior to admission

• the 45-days allowance for room and board has not been consumed yet

• confinement in an accredited hospital of not less than 24 hours

Are you eligible?Are you eligible?

Additional Tips for Better Payment

1. Eliminate down coding by providing complete descriptions

2. Rank procedures by order of importance

3. Don’t send documents not required

4. Submit claims promptly and frequently

5. Complete forms ASAP

6. Fill in all blanks. Type NA

7. Make it a practice to follow up with Claims Dept.

www.philhealth.gov.ph

Contact Details:Contact Details:

qarp@philhealth.gov.ph

0918-9001618